Neonatal jaundice

Background

• Must distinguish between unconjugated and conjugated hyperbili
  • Conjugated is always pathologic

Risk Factors

• Isoimmune hemolytic disease
• G6PD deficiency
• Asphyxia
• Significant lethargy
• Temperature instability
• Sepsis
• Acidosis

Work-Up

• Tbil/Dbil
• CBC (for hemolytic anemia)
• Coombs or T&S (mom & baby)

DDx

Common

• Physiologic
• Breast Milk Jaundice
  • Due to substances in milk that inhibit glucuronyl transferase
  • May start as early as 3rd day, reaches peak by 3rd week of life
  • Unlikely to cause kernicterus
• Breast-Feeding Jaundice (starvation jaundice)
  • Pt does not receive adequate oral intake
    • Results in reduced bowel movement/bilirubin excretion

Uncommon

• Direct (conjugated, post- liver obstructive)
  • congenital biliary atresia
  • neuroblastoma
  • cholesterol cysts
• Cellular
  • hepatitis
  • galactosemia
  • sepsis
  • TORCHS
  • tyrosinemia
  • alpha 1 antitrypsis deficiency
• Indirect (unconjugated, pre-liver)
  • sepsis
  • hypotension
  • rH/ABO incompatibility
  • G6PD Deficiency
  • RBC membrane defects

Treatment

• Breast Milk Jaundice
  • Do not need to routinely d/c breast-feeding
  • Treat w/ phototherapy when necessary
• Breast-Feeding Jaundice
  • Supplement with expressed breast milk or formula
• Exchange transfusion
  • Consider if signs of bilirubin encephalopathy
    • Hypertonia, arching, retrocollis, opisthotonos

Phototherapy Guidelines

See http://bilitool.org/

Age	Low risk pt cut-off	Med risk pt cut-off	High risk pt cut-off
Birth	7.0	5.0	4.0
24h	11.5	9.0	8.0
48h	15	14	10
72h	17.5	15	14
96h	20	17.5	14.5
5+day	21	17.5	15

• Use total bilirubin

Low Risk: >=38wk + no risk factors

Med Risk: (>=38wk + risk factors) or (35-37 wk and no risk factors)

High Risk: 35-37wk + risk factors